EFCOG Contractor Guide for Performance Analysis · EFCOG Contractor Guide 2008-1 ... recurring...
Transcript of EFCOG Contractor Guide for Performance Analysis · EFCOG Contractor Guide 2008-1 ... recurring...
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Table of Contents
Introduction …………………………………………………………….. 1
Discussion ………………………………………………………………. 1
Definitions ……………………………………………………………… 2
Purpose ………………………………………………………………… 3
Performance Analysis Process …………………………………………... 4
References ……………………………………………………………… 10
Appendix A ..…………………………………………………………... 11
Appendix B …………………………………………………………….. 12
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 1
PERFORMANCE ANALYSIS
1.0 Introduction
This document provides guidance for conducting performance analysis of events, such as
occurrences, and of conditions, such those found during assessments.
Performance analysis is a systematic review of selected data of interest to identify
common causes and to determine which conditions have occurred with an unacceptably
high frequency such that corrective actions can be developed to prevent recurrence. The
goal is to prevent a more serious event or an unacceptable repeat of events or conditions
and to drive continuous improvement.
This methodology identifies recurring events that may be reportable and identifies
recurring conditions that may warrant additional analysis and corrective action. This
document provides a methodology (including key process elements) for successfully
completing and documenting the analysis and results. This guidance meets the
requirements in DOE Manual 231.1-2 Occurrence Reporting and Processing of
Operations Information and in DOE Order 210.2 DOE Operating Experience Program..
This methodology identifies repeat and programmatic nuclear safety (PAAA) and worker
safety and health (WSH) non-compliances. These PAAA and WSH non-compliances are
then evaluated for reporting to the DOE Office of Enforcement Noncompliance Tracking
System (NTS). NTS-reportable non-compliances include non-compliances that are
repetitive, and non-compliances that indicate a common breakdown in a program or
program area and are caused by systemic problems having a common underlying cause.
The overall process of performance analysis, from data gathering to reporting the results,
is diagramed in Appendix A.
2.0 Discussion
There are many business reasons for a formal performance analysis process. These
include ongoing protection of the workers, the public and the environment; improving the
cost effectiveness of operations; avoiding the costs resulting from recurring or repetitive
events; preventing violations and civil penalties associated with the failure to effectively
correct and prevent problems; increasing the margin of regulatory and customer
confidence; improving quality and reducing rework.
The DOE has several requirements for performance analysis:
• DOE Manual 231.1-2 Occurrence Reporting and Processing of Operations
Information requires that the contractor will perform ongoing quarterly
performance analysis of events that occurred during the previous four quarters to
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 2
look for trends. It is also requires that the performance analysis evaluate
occurrences of all significance categories plus non-reportable occurrences.
In the DOE Office of Enforcement, Enforcement Process Overview, requires
tracking and reporting of repetitive and programmatic noncompliances.
In the DOE Order 210.2 Operating Experience Program
3.0 Definitions
1. Apparent cause – The most probable cause of a condition or event based upon
readily available information; term is associated with occurrence reporting
2. Condition – Any as-found state, whether or not identified by an event or assessment,
that may have adverse safety, health, quality assurance, operational or environmental
implications. In this guidance, the term condition can be errors in calculation,
anomalies associated with design or performance, items indicating a weakness in the
management process, or identified noncompliances.
3. Control Charts – A control chart is a graphical tool for monitoring changes that
occur within a process, by distinguishing variation that is inherent in the process from
variation that indicates a change to the process..
4. Event - Something significant and real-time that happens (e.g., pipe break, valve
failure, loss of power, environmental spill, earthquake, tornado, flood). Events that
are occurrences are reported and tracked in the ORPS or in local non-ORPS
reportable databases.
5. Groupings – Selected elements on which data searches and sorts are performed.
Groupings can be made up of one or more elements.
6. Non-ORPS Reportable Occurrence - An event or condition identified by the site for
tracking that falls below any threshold for a reportable occurrence.
7. Normalize –Data that is shown as a rate to create an equal basis of comparison. For
examples, events per effort hours, events per work orders, or violations per
inspection.
8. NTS – DOE Office of Enforcement’s centralized noncompliance tracking system for
reporting and tracking PAAA and worker safety and health noncompliances.
9. Occurrence Reporting and Processing System (ORPS) - An unclassified,
centralized DOE database containing Occurrence Reports from the DOE community.
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 3
10. Occurrence Report - A documented evaluation of an occurrence event or condition
that is prepared in sufficient detail to enable the reader to assess its significance,
consequences, or implications, and to evaluate the actions being proposed or
employed to correct the condition or to avoid recurrence. Occurrences are tracked in
the DOE Occurrence Reporting and Processing System.
11. Occurrence – A single or recurring event or condition that adversely affect, or may
adversely affect, DOE (including NNSA) or contractor personnel, the public,
property, the environment, or the DOE mission. Events or conditions meeting the
criteria threshold identified in DOE M 231.1-2, or determined to be recurring through
performance analysis, are occurrences.
12. Performance Analysis - a systematic review of data of interest to identify common
causes and conditions and then to identify those with an unacceptably high frequency
such that corrective actions can be developed and implemented. The goal is to prevent
a more serious event or an unacceptable repeat of the events or conditions
13. PAAA – Price Anderson Amendments Act authorizes DOE to establish and enforce
the nuclear safety rules.
14. Pareto Charts – Displays the frequency of events, conditions or causes to identify
those items that are most frequent and require more in-depth analysis or action to
eliminate defects.
15. Recurring occurrence – A series of two or more events determined by performance
analysis to have an unacceptably high frequency and severity, for which previous
corrective actions failed to prevent repetition.
16. Root cause – The most basic cause that can reasonably be identified, that
management has the control to fix, and for which effective recommendations for
corrective action(s) for preventing recurrence can be generated
17. Trend Chart – Trend charts compare the number of events over time.
18. Watch list – Those conditions or events that are identified through performance
analysis that do not meet the criteria for further reporting but are considered by the
analyst as an indication that additional attention or action may be necessary to prevent
it from becoming a reportable event or condition in the future. The watch list is a tool
for managers.
4.0 Purpose
This document establishes an approach for conducting performance analysis.
Performance analysis is a systematic review of events reported in ORPS and internally-
(site-) reportable events to identify possible recurring occurrences. Repeated events are
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 4
not necessarily recurring occurrences and vice versa. Performance analysis is also a
systematic review of internally- (site-) reportable PAAA and WSH non-compliances to
identify repetitive, systemic or programmatic PAAA and WSH non-compliances for
more in-depth causal analysis. These conditions and events can be analyzed by several
methods to identify the underlying cause and possible latent organizational weaknesses.
Performance analysis is also used to analyze events and conditions for potential lessons
learned
Events may recur when the apparent cause analysis for an individual occurrence was not
effective in determining the cause, or when the corrective actions taken to resolve the
causes were not effective. In each case, repeated events should be reviewed to determine
if they should be classified as potential recurring occurrences. Apparently dissimilar
events (events with different consequences) may be recurring if they have a similar
apparent cause.. If a series of two or more events with common causes or conditions is
determined by performance analysis to have an unacceptably high frequency, a recurring
occurrence is reported. The common causes or conditions are then analyzed such that
appropriate corrective actions can be developed and implemented to prevent more serious
events.
DOE has a graded approach to analyzing occurrences and non-compliances. As part of
this process, DOE requires contractors to determine and report the apparent cause of all
occurrences above significance category 4. A root cause analysis, which is more in-depth,
is also required for occurrences at the higher significance categories of OE, 1 and R.
There are many causal analysis methods that can be used to evaluate an event or
condition. Apparent cause analysis is the method for analyzing occurrences that are
significance category 2 or 3, which are a major portion of all occurrences. For most
occurrences, knowing the apparent cause is sufficient to determine the appropriate
corrective action. A more in-depth analysis of a single event may not yield additional
insight and would not change the corrective action. In addition, reporting cause categories
from the cause analysis tree provides DOE with the capability to analyze events across
the complex.
Performance analysis is also part of the graded approach to implementation. The
performance analysis process identifies additional events or conditions that should be
analyzed using root cause analysis.
5.0 Performance Analysis Process
The performance analysis process includes five basic steps:
(1) Gathering the data
(2) Analyzing the data
(3) Identifying potential problems
(4) Documenting the results of the performance analysis
(5) Reviewing the results with senior management
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 5
5.1 Gathering Data
The parameters for the data should be established based on the analysis objectives and
used consistently to allow for comparisons between analysis results.
5.1.1 Collect and Compile Data
For analysis of occurrences, the DOE Manual 231.1-2 requires analysis of all events
during the previous four-quarter period. The time period should remain consistent for
each of the quarterly analysis. If conditions from assessments are included in the analysis,
then the variations caused by assessment frequencies, subjects or types need to be
considered and addressed in the analysis. In cases with variation, the data may need to be
normalized.
DOE requires contractors to include site-specific data for non-reportable events in the
analysis. Examples of non-reportable events may include illness and injury reports,
radiological doses and events, minor spills, and emergency response logs or conditions
identified by assessment results.
The analyst will need to determine the minimum set of information needed for successful
analysis. Contractors may choose to establish additional internal reporting requirements
in order to have the information they need to conduct the analysis. For example, the
significance category 4 occurrences, the internally- (site-) reportable occurrences and
conditions found by assessments may not have cause codes, unless required by the
contractor.
Once the data needs are identified and collected for the occurrences and the selected
conditions, the data needs to be entered into a one or more database as it becomes
available and formatted to facilitate analysis. The data will need to be reviewed and
sorted to ensure it is complete, accurate, and does not include duplicate entries.
5.1.2 Determine Elements and Groupings
The analyst will sort the data into appropriate groupings based on reporting objectives
and occurrence attributes that are identified by the contractor and the elements to be
analyzed. Selected groupings may include elements such as cause codes, deficiency
description types, affected items and equipment, DOE Headquarter keywords, reporting
criteria, organization, time, and significance category, locations, work groups, Reporting
Criterion/Criteria, Significance Category.
The selection of the groupings is dependent on the reporting objectives. Analysis results
will be more definitive and revealing if the groupings include comparable and directly
related attributes. For example, if the groupings include only Final reports, then the
attributes will be final causes and conclusions. The analyst may want to look at corrective
actions in the analysis to identify common elements. The contractor determines which
groupings should be used based on current reporting objectives and previous analyses.
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 6
5.2 Analyze Data
The techniques discussed below include both statistical and qualitative methods and
provide a framework to assist in conducting performance analysis. While the methods
described below can be used to analyze event data, other site-specific processes can also
be used to support this analysis.
The data may be analyzed by personnel with expertise in statistical analysis. The overall
performance analysis process; however, will likely include many different health, safety
and environmental protection specialists and managers. This, of course, will depend on
the contractor’s organizational structure and assigned roles and responsibilities.
The analyst examines trends and data considering “Who”, “What”, “Where”, “When,”
“Why,” and “How” the event occurred. The first step is to identify which events appear to
be different from the other events. The analyst then determines the relationship the
elements have together within the context of the subject or grouping. The count of items
in itself does not yield useful a result; the analyst will need to understand the occurrences
and their significance.
5.2.1 Pareto Charts
The Pareto principle states that 80% of the impact of the problem will show up in 20% of
the causes. A bar chart that displays by frequency or quantity, in descending order, will
identify the most important defects. This chart-type is used to identify if the Pareto
principle is evident in the data. If the Pareto principle is evident, about 20% of the
categories on the far left will have about 80% of the impact on the problem. A Pareto
chart is used to graphically summarize and display the relative importance of the
differences between groups of data.
In a Pareto chart, the analyst graphs the number of items (events, causes codes,
facilities/operations/organizations) within a chosen grouping. Pareto charts can be used to
visually display the major contributor to a grouping and help identify areas for further
analysis.
The data should be “normalized” so that comparisons are made that are useful to the
analyst. For example, when preparing a Pareto chart on electrical shocks, it would not
add value to compare the maintenance organization to administrative organizations,
because the maintenance organization has more frequent opportunity for electrical shock.
It may be valuable; however, to compare the programmatic organizations with similar
expected frequencies.
Example of Pareto chart is displayed in Appendix C.
Questions to ask when reviewing Pareto charts may include:
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 7
• What is the most frequent common underlying cause for a series or group of
events?
• Do related series or groups of events, having the same underlying cause, occur
most frequently within a single organization, facility or operation?
• Have multiple control failures taken place within the boundaries of a single
grouping indicating a common breakdown in a program or area of a program?
• Do the causal factors of a series or group of events indicate possible systemic
problems?
5.2.2 Trend Charts
Trend charts compare the number of events over time. They can be used to measure the
significance of performance in a single point of time compared to the past and to project
future performance. Using a trend chart, the analyst can determine the impact of actions
taken and whether corrective actions are effective. In evaluating trend charts, one must
consider what variable that may affect the number of events identified. If the definition of
the event is changed or an activity has been added to increase the likelihood of
identification and reporting, the trend results will be affected.
An example of trend chart is displayed in Appendix C.
Questions to ask when reviewing trend charts may include:
• Did the trending data for the series or groping of events indicate a positive
trend?
• Did the trending data for the series or group of events indicate a negative
trend?
• Can the trend be correlated to specific activities, such as assessments, changes
in processes, changes in requirements, etc?
5.2.3 Control Charts
Control charts are designed to look for specific variations outside of the normal range. A
control chart is a graphical tool for monitoring changes that occur within a process, by
distinguishing variation that is inherent in the process from variation that indicates a
change to the process. This change may be a single point or a series of points in time -
each is a signal that something is different from what was previously observed and
measured.
Control charts are used to identify changed levels of variability. By establishing control
charts, one can analyze process variability and determine when something unusual is
present. If the change is significant, the analyst then looks for the source(s) of the
variability. The use of control charts can show if the process is in “statistical” control so
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 8
that an over-reaction to events can be avoided. Process control charts can show gradual
trends toward the established limits so that those in direct control of the operation can
avoid an abnormal event. In the example of electrical shocks, the frequency of electrical
shocks at different energy levels can be graphed and compared to the control limits
expected in “normal” operations. When these limits are exceeded, we can expect to find
sources of the variation. These should be investigated. Control limits are established
based on the historical data and current expectations. Control limits based on standard
deviations set the likelihood of occurrences.
An example of a control chart is displayed in Appendix C.
Questions to ask when reviewing control charts may include:
• Is the frequency of an event or cause acceptable?
• Is the source of the variability of concern?
• Is there an undesirable change in the frequency of an event or cause?
5.2.4 Relationship Analysis
The analysis methods described in this section complement the statistical analysis
methods described above. The statistical analysis methods above lead the analyst to
specific areas with common elements for further relationship analysis. In addition to
looking at events, the apparent causes of dissimilar events may be related and should be
analyzed. This is the point at which the relationship analysis is applied to a smaller set of
events and conditions to provide insight into management, operations and programs. For
the most part, reporting is required based on the consequences of an event or the
seriousness of the noncompliance. This relationship analysis looks at underlying causes
of multiple events or conditions and of multiple noncompliances. Events in which the
consequences appear unrelated may in fact have common causes that would be identified
by this analysis. The analysis can determine the causes of the events or conditions using
the “Why-Because,” “5-Whys,” “Why-staircase,” method or another suitable method.
The results can be diagramed such that the common causes are connected. The goal of
relationship analysis is for the analyst to look for indications of an ineffective or weak
program, a common underlying cause, or indications of a breakdown in management
control. In cases where the cause of the problem involves human performance, it is
necessary to look beyond human behavior and to examine and determine the error
precursors and latent organizational weaknesses that may have contributed to the human
performance problem.
Questions to ask when looking for commonality across dissimilar events may include:
• Do the apparently isolated series or groups of events indicate a series of
common work process breakdowns or a series of common issues?
• Do apparently isolated series or groups of events collectively indicate a
program weakness?
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 9
5.3 Identifying Potential Problems
If a series of two or more events with common causes or conditions under the control of
the contractor is determined by performance analysis to have an unacceptably high
frequency, a recurring occurrence is identified.
If the data analysis results in the identification of a series of noncompliances that are
considered repetitive or if the analysis indicates a common breakdown in a program or
program area or systemic problems having a common underlying cause, the results
should be reviewed for reporting requirements.
If the analysis reveals operating experience that would be beneficial to share with others,
a lessons learned could be prepared.
5.4 Management Review
If the data analysis results in the identification of non-compliances that are considered
repetitive or if the analysis indicates a common breakdown in a program or program area
or systemic problems having a common underlying cause, the results are presented for
senior managers to review. The senior managers discuss the results of the performance
analysis and either validates the analysis or request additional investigation, as needed.
Often, the recurring issues identified through performance analysis will be at the
contractor level and can only be addressed by senior management commitment (a single
department cannot “solve the problem”). In addition, huge benefits of a robust
management review process are the enabling opportunities for awareness of emerging
trends, resulting in proactive management opportunities to possibly prevent “recurring”
issues.
The management review is an important element of the overall performance analysis
process. Having a thorough and dynamic management review not only ensures that there
are appropriate focuses and proper balances in the analysis process, but also confirms that
management owns the process and the results of the process.
5.5 Document the Performance Analysis
The performance analyst documents the results of the analysis including the identification
of events or conditions that are considered repetitive or if the analysis indicates a
common breakdown in a program or program area or systemic problems having a
common underlying cause recurring in a report.
DOE requires contractors to identify and report recurring occurrences in ORPS and to
identify and report repeated non-compliances in the nuclear safety and worker safety and
health Noncompliance Tracking System. The reporting requirements should be consulted.
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 10
6.0 References
DOE Manual 231.1-2, Occurrence Reporting and Processing of Operations Information
DOE Guide 231.1-1, Occurrence Reporting and Performance Analysis Guide
DOE Office of Enforcement, Enforcement Process Overview
DOE Order 210.2, Operating Experience Program
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 11
Appendix A
Performance Analysis Process
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 12
Appendix B
Statistical Charts and Matrixes
Pareto Charts
Occurrence Reporting Criteria
1 1 1 1 1 1 1 1 1
2 2 2
4
6
7
9
14
12
21
22
24
25
26
0
5
10
15
20
25
30
2A(5
)-Per
sonn
el e
xpos
ure
10(5
)-Pro
mpt
not
ifica
tion
repo
rting
optio
n
2B(1
)-Any
unp
lann
ed fi
re o
r exp
losi
on
3A(2
)-TSR
4A(1
)-Per
form
ance
deg
rada
tion
of a
ny
Safe
ty C
lass
4B(4
)-Any
faci
lity
evac
uatio
n
4B(5
)-A fa
cilit
y op
erat
iona
l eve
nt c
ause
by d
evia
tion
from
pro
cedu
re
5A(4
)-Rel
ease
of h
azar
dous
sub
stan
ce
6A(2
)-Los
s of
radi
oact
ive
mat
eria
l
6D(3
)-Any
ons
ite c
onta
min
atio
n
10(4
)-Inq
uirie
s to
Hea
dqua
rters
2C(2
)-Loc
kout
/Tag
out
4C(3
)-Dis
cove
ry o
f any
def
ectiv
e ite
m
10(3
)-A n
ear m
iss
1(1)
-An
Ope
ratio
nal E
mer
genc
y
9(2)
-Non
com
plia
nce
notif
icat
ions
3B(2
)-Pot
entia
l ina
quat
e sa
fety
anal
ysis
4A(2
)-Saf
ety
clas
s SS
C
2A(6
)-Occ
upat
iona
l Illn
esse
s/ In
jurie
s
4C(2
)-Sus
pect
/cou
nter
feit
3B(1
)-Pos
itive
unr
evie
wed
saf
ety
ques
tion
10(2
)- M
gmt C
once
rns
6B(4
)-Ide
ntifi
catio
n of
ons
ite le
gacy
Qua
ntity
0%
2%
4%
6%
8%
10%
12%
14%
16%
Perc
enta
ge
SAMPLE DATA
Cause Code Categories
1 1 1 1 12 2 2
3 3 3 34 4 4
5 56
78
9
11 11
25
0
5
10
15
20
25
30
Des
ign
Ver
ifica
tion
/ In
stal
latio
n V
erifi
catio
n LT
A
Ext
erna
l Phe
nom
ena
Ope
rabi
lity
of D
esig
n /
Env
ironm
ent
LTA
Sup
ervi
sory
Met
hods
LT
A
Ver
bal C
omm
unic
atio
n LT
A
Cal
ibra
tion
for
Inst
rum
ents
Les
s T
han
Ade
quat
e
Insp
ectio
n/ t
estin
g LT
A
Writ
ten
Com
mun
icat
ion
Met
hod
of P
rese
ntat
ion
LTA
Per
iodi
c/C
orre
ctiv
e M
aint
enan
ce L
TA
Res
ourc
e M
anag
emen
t LT
A
Wor
k P
ract
ices
LT
A
Ski
ll B
ased
Err
ors
Cha
nge
Man
agem
ent
LTA
Des
ign
/ do
cum
enta
tion
LTA
Rad
iolo
gica
l / H
azar
dous
Mat
eria
l Pro
blem
No
Tra
inin
g P
rovi
ded
Tra
inin
g M
etho
ds L
ess
Tha
n A
dequ
ate
Des
ign
outp
ut L
TA
Def
ectiv
e, F
aile
d or
Con
tam
inat
ed
Kno
wle
dge
Bas
ed E
rror
Mat
eria
l con
trol
LT
A
Wor
k O
rgan
izat
ion
& P
lann
ing
LTA
Writ
ten
Com
mun
icat
ion
Con
tent
LT
A
Man
agem
ent
Met
hods
Les
s T
han
Ade
quat
e
Qu
anti
ty
0%
5%
10%
15%
20%
25%
Per
cen
tag
e
SAMPLE DATA
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 13
Control Chart
Total Number ORPS Occurrences
Significance Categories (OE, SC1, R, SC2, SC3, SC4)
SAMPLE DATA
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Jan-0
4
Feb-0
4
Mar-
04
Apr-
04
May-0
4
Jun-0
4
Jul-04
Aug-0
4
Sep-0
4
Oct-
04
Nov-0
4
Dec-0
4
Qu
an
tity
Total Occurrences Mean Upper Confidence Limit
SAMPLE DATA
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 14
Trend Chart
Cumulative Dollective Dose
0
5
10
15
20
25
30
35
40
1998 1999 2000 2001 2002 2003 2004 2005 2006
Pe
rso
n-r
em
Annual Doses
0
5
10
15
20
25
30
35
40
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
Pe
rso
n-re
m
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 16
ASSOCIATED HUMAN FACTOR COUPLETS
Associated Couplet Human Factor A3Bx Node
Cause Code B1-Skill B2-Rule B3-Knowledge B4-Work Pract. Total
A2-Equip/Mat'l B2-PM 1 1
B4-Mat'l Cont 2 2
A4-Mgmt B1-Mthds 1 1
B2-Res. Mgmt 6 3 9
A5-Comm B1-Method 1 1
B2-Content 1 2 3
A6-Training B2-Training LTA 8 4 1 2 15
A7-Other B1-External 1 1
None 2 3 2 7
Total 21 7 7 5 40
SAMPLE DATA
EFCOG Contractor Guide 2008-1
Integrated Safety Management & QA Working Group
Page 17
CROSS CUTS OF REPORTING CRITERIA AND APPARENT CAUSE CODES
OE
Mgm
t co
nce
rns
Ne
ar
Mis
s
Occu
pa
tio
na
l
Illn
esse
s/I
nju
rie
s Fire
Locko
ut/
Ta
gou
t
TS
R
US
Q/P
ISA
Po
ten
tia
l L
TA
sa
fety
ana
lysis
Pe
rfo
rman
ce
deg
rad
atio
n
Fa
cili
ty
eva
cu
atio
n
Loss R
ad
Mate
ria
l
On
site
Leg
acy
On
site
Co
nta
min
atio
n
CAUSE CODES 1(1) 10(2) 10(3) 2A(6) 2B(1) 2C(2) 3A(2) 3B(1) 3B(2) 4A(1) 4B(4) 6A(2) 6B(4) 6D(3) Total
A1-Design
B2-Output 1 1 1 1 4
B3-Doc LTA 1 3 4
B4-Install Verif. 1 1
A2-Equip/Mat'l
B1-Calib. 1 1 2
B2-Maint. 1 2 3
B3-Insp/Test 1 1 2
B4-Mat'l Control 1 2 1 4
B6-Defect 1 2 1 1 1 6
A3-Human
B1-Skill 7 9 7 9 9 6 13
B3-Knowledge 1 8 5 6 1 1 1 6
B4-Work 2 1 3
A4-Mgmt
B1-Methods 1 3 1 2 1 8
B2-Resource 2 1 3
B3-Planning 1 2 1 1 1 6
B5-Change Mgmt 1 1 2
A5-Comm.
B1-Methods 1 1
B2-Content 2 1 2 2 1 2 10
B4-Verbal 1 1
A6-Training
B1-No Training 1 2 1 4
B2-Methods 5 5
A7-Other
B1-External 1 1
B2-Rad/Hazardous 2 1 3
Total 11 16 6 15 3 2 10 11 8 1 2 1 3 1 92
SAMPLE DATA
SAMPLE DATA